Section I: Immunosuppression

Defining Immunosuppression

Nurses already know that patients who are immunosuppressed need to be assessed for and protected from infections. But before you roll your eyes, it is important to be on the same page by reviewing immunosuppression - from the basics to understanding how certain medications can affect the immune system. Savvy patients, especially those with chronic illnesses, really do know just how susceptible they can be to infections – so listen to them!  Never make assumptions about how immunosuppressed a person is.

The basic definition states that "immunosuppression is the partial or total inhibition of a person's normal immune response which can be caused by disease, administration of drugs, or surgery" (Dictionary.com, 2016). There are two main types of immunosuppression: Primary and Secondary (Acquired). Primary immunodeficiency occurs when the body's immune system does not work normally or is nonfunctioning. Most cases are genetic, rare and usually discovered during childhood (Carey, 2016). For the purposes of this article, we will focus on the more common type: Acquired Immunodeficiency.


Types of Aquired Immunosuppression

Acquired immunosuppression is also known as secondary immunosuppression and, as the name suggests, is caused by certain medical conditions, medications, and surgery. Below is a list of common types of acquired immunosuppression (Carey, 2016):

A review of this list should already be causing you to ask questions. Are we protecting these types of patients in my healthcare setting? Does the nursing assessment adequately address the risk from immunosuppression? Do the care plans include preventing infection due to malnutrition or biologic therapy? How do I make sure that the patient is protected if they cannot be isolated?


Immunosuppression Pearls

Immunodeficiency is variable between and within patients. Regardless of the cause, medication, dosage, medical condition, or lab values - no two patients are alike. Furthermore, each patient will respond differently to medications and to potential infection threats at different time points (Wilkinson, 2012). Never compare any patient’s immunity to another or assume a patient is less immune than another.

Lab values can be normal. Many patients who have been taking immunosuppressants, biologics, and even some chemotherapeutic drugs can have a normal white blood cell count. The scary part is that the patient can demonstrate a normal WBC and be afebrile the presence of an infection (Siegel et al, 2012). This is why determining bed placement or the need for protective isolation should not be solely based on the labs. Transplant recipients, for example, may have normal lab studies despite taking two or three immunosuppressant medications for a prolonged period of time.

Because the immune response varies, the nurse must not take for granted that long term use of immunosuppressants will decrease their risks. The risk of infection, cancer, and other problems from immunosuppression does not get better with long term use. Many patients are on these medications for the rest of their lives. They may be on a combination of immunosuppressant medications (such as a rheumatoid arthritis patient on methotrexate along with a biologic). Even after discontinuing the medications, the immunosuppressant effect can last for weeks or months or even a year depending on the medication (Sandofi, 2016). Long term users are at risk for antibiotic resistance from multiple infections. While drug dosage may be adjusted or lowered as the patients’ condition warrants, this does not necessarily mean the risk for infection decreases.

Immunosuppressive medications affect the whole body. While each medication has its own list of common short and long term side effects, it is important not only to assess for infection in this population, but to be aware that other systems may be impacted. Some of these may be familiar (such as prednisone and bone loss), but here are a few other examples:



Types of Drug-Induced Immunosuppressive Agents

The focus of this article is on the biologics and MABs, but the importance of steroids, immunosuppressants, and chemotherapeutics cannot be overstated. All of these medications suppress the immune response. Remember that many patients currently take a combination of these drugs or started on these medications before being placed on the biologics. Another point here is that these drugs may have been developed for one purpose, and then later used (off-label or FDA approved) to treat other conditions.

Steroids

Nurses must understand the impact steroids can have on the immune system. Corticosteroids are typically the first line of drugs used to treat asthma, cancers, autoimmune diseases, and many other conditions. They are also used in conjunction with other medications to prevent rejection in transplant recipients or alleviate symptoms of rheumatoid arthritis. Steroids can be used on a short-term basis or for a lifetime. As you know, steroids can and do increase the risk of infections and have other adverse side effects. Asthmatics, for example, are more prone to thrush and fungal respiratory infections (More, 2016). While corticosteroids may not have the same mechanism of action on the immune system as those of a MAB class biologic, do not underestimate their immunosuppressive powers!

Immunosuppressant Medication

Immunosuppressant Class Medications

Nearly all solid organ transplant recipients, along with many rheumatoid arthritis, irritable bowel syndrome, and certain cancer patients, have used immunosuppression class drugs to prevent organ rejection, alleviate symptoms of their disease, and retard cell growth. As stated above, these drugs are often used in combination with other immunosuppression, biologics and steroids. These drugs for the most part have been around for decades so side effects and serious risks are well documented. Transplant recipients must take them day after day and year after year in order to help prevent organ rejection. The risk for infection is especially high in the first few weeks after a transplant due to induction therapy and increased dosages, but the long term risk for serious and sometimes life-threatening infections is ever-present.

Chemotherapeutics

Nurses know that this class of medications is used to treat or kill cancers of various types. It is a given that many of these drugs are immunosuppressive because we want them to be! Many of these medications are not specifically targeted to a particular cancer cell, so all cells can be destroyed, thus leading to severe immunosuppression secondary to leukopenia. Some chemotherapeutic agents have been used for other conditions such as rheumatoid arthritis (Methotrexate) and transplant (Azathioprine). These drugs are variable in their use and duration and often used in combination with other similar drugs. Biologics are now playing a bigger role in the treatment of cancer via immunotherapy. Monoclonal antibodies are often used since they help the body’s own immune system target specific cancer cells (American Cancer Society, 2015).

Biological Therapies

You will learn in the next section that biologics are used to treat or diagnose many specific medical conditions. MABs have many uses and make up most of the biologics on the market.



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